Determinants of undernutrition among settled pastoralists' children aged 6–59 months in Kenya

Abstract The transition from nomadism to sedentary lifestyle has introduced changes in diets and undernutrition is endemic among settled pastoral households. This study aimed to investigate the underlying factors affecting stunting, underweight, and wasting of children aged 6–59 months in Marsabit County, Kenya. A cross‐sectional household survey was conducted in six wards capturing pastoral, agro‐pastoral, and urban livelihood practices. Using multistage sampling method, 394 children aged 6–59 months participated with written consent from the caregivers. A pretested questionnaire and anthropometric measures were used during data collection. Population characteristics were summarized into means and proportions, while chi‐square and analysis of variance were used to evaluate associations between variables. Backward logistic regressions were used to explore predictors of stunting, underweight, and wasting, respectively. The results showed that the mean Height for Age Z‐score, Weight for Age Z‐score, and Weight for Height Z‐score were −1.51, 1.54, and 1.02, respectively. The prevalence of stunting, underweight, and wasting was 38.1%, 23.0%, and 18.5%, respectively. The age of child, source of drinking water, and waste disposal were some of the main factors influencing stunting among children. In conclusion, the prevalence of undernutrition was high compared to the World Health Organization recommended cutoffs. Water sources hygiene, and caregiver's income were some of the main predictors of undernutrition among children. Development agencies need to focus on the supply of potable water, access to toilet facilities, in addition to nutrition education on hygienic complementary feeding practices among pastoral caregivers.

foods such as milk and blood toward purchased goods, particularly grains and pulses.While all age groups within a household consume the same food, complementary meal preparation and handling for infants and toddlers between the ages of 6 and 59 months differ from those for adults in terms of the degree of processing and even feeding practices.One of the main causes of undernutrition, which manifests as stunting, wasting, and underweight in children aged 6-59 months, pertains to suboptimal supplemental feeding practices by caregivers.
The impact of child undernutrition on under-five children's linear growth, health, and cognitive development remains a public health problem (Kassa et al., 2016;Matonti et al., 2020).However, current research has limited information on the effect of settlement on underlying causes of undernutrition in this population.Several studies have found a link between children's nutritional status and underlying variables.Studies conducted in Uganda found that being a male and falling into certain age brackets, as well as poor sanitation, increased the odds of wasting among children under the age of 5 (Kinyoki et al., 2015;Obeng-Amoako et al., 2021;Okidi et al., 2022).Other factors linked to child malnutrition include parental income and education levels (Khan et al., 2019).While data on children's nutritional status have been collected for emergency treatments in pastoral areas, there is a scarcity of knowledge on the underlying factors influencing the nutritional status of children, particularly among settled pastoralists.Therefore, the purpose of this study was to assess the prevalence of nutritional status and its associated underlying determinants in settled pastoral children in northern Kenya using Marsabit County as a case study.The findings of this study can inform policy formulation aimed at strengthening nutrition-sensitive development initiatives among settling pastoral communities.

| Key messages
• As nomadic households settle in urban centers and satellite camps under poor sanitary conditions, challenges such as malnutrition abound.
• The main factors undermining child nutritional status included the age of child, source of drinking water, fecal waste disposal, and caregiver's income.
• There is need to improve the phytosanitary conditions such as increased access to toilets and supply of potable water for domestic use in areas occupied by these nomadic households.

| Design and study population
A cross-sectional study of settled pastoral households with children aged 6-59 months was performed.The research was carried out in Marsabit County, northern Kenya (Figure 1), in the months of October and November, 2020.The research was carried out in the wards of Laisamis, Logologo, Karare, Central, Sagante/Jaldesa, and Bubisa, which reflected distinct agro-ecological zones, social, cultural, and livelihood patterns.Children under the age of 6 months, as well as those who were chronically or terminally ill, were excluded from participating in the study.

| Sampling procedure
The sample size was determined following the methodology proposed by Magnani (1997), focusing on a critical indicator, in this case, a minimum meal frequency of 49% in Moyale subcounty (Opiyo, 2018) with a 10% expected change in minimum meal frequency.The study used a multistage sampling method outlined by Mugenda and Mugenda (1999).A total of 394 households with an index child aged 6-59 months were selected.The first stage involved purposive selection of counties, subcounties (Laisamis, Saku, and North horr), and wards (Karare, Laisamis, Logologo, Marsabit Central, Sagante/Jaldesa, and Bubisa).Simple random sampling was then used to choose sampling clusters at the location level.A list of target children from various locations within each of the six wards was then compiled with the support of health officials and local leaders conversant with the study areas.
The number of index children per ward was allocated proportionately to the population size and formed the sampling frame.In cases where more than one child between 2 and 5 years of age was encountered, the index child selected was the child aged 6 months and be the last born among the under-five.Additionally, in cases of twins, their names were written in separate papers, folded, and the caregiver given a chance to pick one paper with a name.A systematic sampling procedure was employed, in which each household served as a sampling unit.The consent form was translated into Kiswahili and orally translated into local languages when necessary.
F I G U R E 1 Map of Marsabit County showing study sites.

| Social, economic, and demographic questionnaire
Data pertaining to children, including their birth date, birth weight, sex, and vaccination status, were gathered from their health clinic records.In addition, a pretested semi-structured questionnaire was administered to the child's caregiver to obtain information regarding parental education levels, occupation, marital status, family size, and water and sanitation.The questionnaire also covered topics such as livestock ownership and income source.

| Anthropometric measurements
Anthropometric measurements were conducted in accordance with the guidelines provided by the World Health Organization (WHO, 2006).The children's recumbent length or height was measured using a portable stadiometer (UNICEF, United Nations Children's fund), ensuring accuracy to the nearest 0.1 cm, as recommended by UNICEF.Weight measurements were obtained using a standard electronic scale (seca GmbH & Co. KG, Hamburg, Germany), with precision up to the nearest 100 g.

| Data analysis
The data cleaning, management, and analysis were conducted using SPSS software program version 22 (IBM Statistics in Chicago, IL, USA).
Backward logistic regression analysis was performed to investigate the potential factors influencing stunting, underweight, and wasting as outcome variables and presented as crude and adjusted odds ratios.The outcome variables were examined for the general population and separately for each ward.All data were analyzed at the 95% confidence level.1).
Table 1 provides a summary of household access to and utilization of water in the study areas.The daily average time taken to collect water was 58.37 minutes (p < .001).Caregivers in the Karare ward spent significantly more time accessing water, followed by Bubisa and Marsabit Central.On the other hand, households in Sagante/Jaldesa, Laisamis, and Logologo spent relatively less time fetching water from the various sources (Table 1).
Table 2 provides a summary of the percentage of households using different types of toilet facilities and fecal waste disposal methods.The study shows that the majority of households using pit latrines were from the Sagante/Jaldesa ward, followed by Marsabit Central, Laisamis, Karare, and Logologo.The Bubisa ward did not register any pit latrines; however, there were communal pit latrines constructed by development agencies.The lack of pit latrines was more prevalent in lowland wards (Laisamis, Karare, Logologo, Sagante/Jaldesa, and Bubisa) than  Table 3 provides a summary of the prevalence of stunting, wasting, and underweight among children in the six wards, categorized by age groups.The study revealed significant (p < .001)differences in overall moderate (33%) and severe (3.8%) stunting across the wards.
Karare had the highest prevalence of underweight among children aged 6-59 months, followed by Sagante/Jaldesa, Marsabit Central, Logologo, and Bubisa (Table 3).In terms of sex, 27% of males and 25% of females were moderately underweight, while 0.5% of males and 2.0% of females were severely underweight.Moderate to severe underweight among female children ranged from 19% in Logologo to 35% in Laisamis, while among male children, it ranged from 10.5% in Logologo to 58.3% in Karare.

| Social, economic, demographic, and environmental factors influencing undernutrition among children
The main predictors of underweight included household head's highest level of education, age of the child, source of drinking water, caregiver's income, and child's weight, respectively (Table 4).Children residing in households where the household head attained at least primary education exhibited a reduced like-    Severe 0 (0.0) a 0 (0.0) a 0 (0.0) a 1 (6.7) a 1 (5.6) a 0 (0.0) a 2 (3.2) (Continues) underweight.Additionally, every unit increase in age reduced underweight by 0.031 units (Table 4).
At the ward level, the results reveal that in the Laisamis ward, the weight of the child emerged as the sole significant predictor of wasting (AOR = 0.066, 95% CI: 0.004-0.979,p = .048).

| DISCUSS ION
The levels of underweight, stunting, and wasting described in the current study (Tables 3 and 6 Furthermore, comparing the findings of the current study to those of the research works conducted in Uganda (Nankinga et al., 2019) and Senegal (Badiane et al., 2021), the prevalence rates of undernutrition were found to be higher in the present study.Conversely, in the rural Kaski District, Nepal.The difference in prevalence rates may be attributed to differences in household's socioeconomic sta- This may present with poor and dusty environmental conditions that predispose children to diarrhea-causing foodborne microorganisms.
Numerous studies have investigated the association between stunting and various caregiver, child, and environmental factors (Ireri et al., 2021;Adeyonu et al., 2022;Mbijiwe et al., 2022).The consumption of contaminated water and lack of access to toilets can expose children to enteric diarrheal microorganisms, such as Escherichia coli and Salmonella spp., which are often associated with consuming contaminated food and water (Okidi et al., 2022).
These findings here align with those of previous studies conducted among nonpastoral children in South Nikuman District, Cambodia (Blaney et al., 2019) and Indonesia (Lukman et al., 2022), pastoral households in the Karamoja region (Okidi et al., 2022), rural areas of North Sudan (Sulaiman et al., 2018), pastoral communities in Mieso-Mulu District, Somali Regional State, Eastern Ethiopia (Geletaw et al., 2021).Furthermore, the findings in the current study compare well with those of Nsubuga et al. (2022) who reported an association between stunting and diarrhea among children in Uganda, and were also consistent with the findings of Sinha et al. (2018) among children in India.
Among pastoral households, common pathways for microbial contamination of infant complementary foods may include the use of raw or poorly cooked animal source foods.Enteric infection by

TA B L E 4 (Continued)
foodborne pathogens can damage the mucosal layer of the intestine, followed by the activation of eae and other genes, causing dissolution of the normal microvilli structure.The bacterium then binds closely to the epithelial membrane via the protein intimin causing death of the epithelial cells and loss of the microvilli of the intestine.This results in the loss of nutrients and subsequent wasting and physical growth retardation (Forshell & Wierup, 2006).
These findings emphasize the importance of addressing access to safe drinking water, access to toilet facilities, caregiver's income, The latest research also revealed that unemployment among mothers, households led by wage earners, and the age of the child had a decreasing impact on stunting.This suggests that mothers who dedicate more time to caring for their children are less likely to witness child stunting.A study conducted in Dhaka, Bangladesh also reported that children of working mothers had nearly twice the odds of being stunted than children of nonworking mothers (Win et al., 2022).Nevertheless, multiple studies have indicated that children whose parents are employed are less susceptible to stunting (Ahmed et al., 2022;Yani et al., 2022).Additionally, income generated from labor-related activities may influence food accessibility, leading to improved food security and consequently reduced stunting among children.The high rates of stunting within the age brackets of 24-35 months and 48-59 months witnessed in the current study may be attributed to short gestation spacing that gives preference to younger children and early weaning using poorly formulated complementary foods among pastoral communities.The results from the current study are consistent with findings from another study by Kang et al. (2018) et al., 2021).This phenomenon may be attributed to poor initiation of complementary feeding practices among pastoral households in Marsabit (Galgallo, 2017).
The association between distance to the nearest market center and stunting in the Karare and Laisamis wards was also observed (Table 5).Access to nearby markets can indirectly affect the nutritional status of young children through inability to regularly access fresh and nutritious foods sourced from food markets, technology adoption, employment opportunities, and the prices of agricultural products (Agyei-Boakye, 2022; Weatherspoon et al., 2019).
Overall, the predictor model highlighted the age of the index child as a significant factor influencing stunting, wasting, and underweight across the wards.The higher stunting in Laisamis compared to the other wards may be attributed to drought conditions that prevailed at the time of conducting this study ( The current study also indicates that advancement in the mean age of child increased the likelihood of child being underweight by a factor of 1.8.This may be attributed to food insecurity and poor weaning practices that tend to focus on infants as compared to older children in the family (Wolde et al., 2015).
This study was conducted during dry season when caregivers could not access milk from livestock.On the other hand, education of household head, safe disposal of fecal waste, and weight of the child showed reduced the likelihood of a child being underweight.
In which similarly linked younger caregivers with undernutrition in young children.
With a mean caregiver age of 28 years, it is evident that a significant proportion of children in this ward are at an elevated risk of undernutrition.This risk may be exacerbated by the high levels of illiteracy observed among households, reaching 66%.Previous studies have shown that the educational levels of caregivers have a notable impact on childhood undernutrition (Clarke et al., 2021;Paul & Saha, 2022;Stamenkovic et al., 2016).Education plays a pivotal role in empowering women to access essential healthcare information, thereby promoting better nourishment for their children (Iftikhar et al., 2017).Furthermore, improved education enhances women's prospects for securing decent employment and income, which in turn afford them greater autonomy in decision-making regarding food choices for their children (Adeyonu et al., 2022;Iftikhar et al., 2017).
Moreover, the present study has revealed that family size exerts a significant influence on in the Sagante/Jaldesa Furthermore, caregiver's monthly income was found to significantly impact wasting and underweight in the Sagante/Jaldesa ward, while only predicting underweight in the Bubisa ward.Higher income levels afford caregivers the opportunity to make informed decisions regarding food purchases, thereby enhancing dietary diversity, particularly for complementary foods.Notably, in this study, 69% of caregivers were classified as low-income earners, with a monthly income of $33 USD (see Table 1).

| CON CLUS ION
This study has shown that the prevalence of stunting, wasting, and undernutrition is above WHO standards.The main predictors of undernutrition included the age and weight of the index child, source of drinking water, waste disposal methods, and caregiver's characteristics, such as age, income, education, and family size.Development agencies need to focus on the supply of potable water, access to toilet facilities in addition to nutrition education on hygienic complementary feeding practices, and regular visits to health facilities to monitor the child's nutritional status should be encouraged among the pastoralists in Kenya.
in the urban ward in Marsabit Central.In such circumstances, many affected households (94.9%) resorted to open defecation, either in the open field or in the bush (p < .001).Only 5.1% of households without pit latrines preferred to use their neighbor's toilet facility.Open defecation was practiced more in pastoral lowland wards, such as Karare, Laisamis, Bubisa, Logologo, and Sagante/Jaldesa.

Figure 4
Figure 4 presents a summary of anthropometric Z-scores for nutritional status indicators among children in Marsabit.The mean HAZ, WAZ, and WHZ were −1.51, 1.54, and 1.02, respectively.Children in stunting (AOR = 0.257, 95% CI: 0.102-0.645,p = .004).A greater distance to the nearest market center was significantly associated with an increased likelihood of stunting in children in Karare ward by a factor of 1.2 (AOR = 1.151, 95% CI: 1.031-1.285,p = .012).The age of the child was likely to significantly affect stunting in the Sagante/ Jaldesa (AOR = 1.088, 95% CI: 1.026-1.153,p = .005)and Bubisa (AOR = 1.116, 95% CI:1.029-1.210,p = .008)wards, respectively lihood of being underweight (COR = 0.544, 95% CI: 0.319-0.928,p = .025).Furthermore, the age of the child emerged as a significant factor associated with an increased probability of underweight (AOR = 1.844, 95% CI: 1.502-2.264,p < .001).Notably, children from households accessing drinking water from public water pans demonstrated a decreased likelihood of experiencing underweight conditions (AOR = 0.318, 95% CI: 0.109-0.925,p = .035).Furthermore, higher caregiver income was associated with a lower likelihood of child underweight (AOR = 0.036, 95% CI: 0.003-0.467,p < .05).The child's weight (AOR = 0.013, 95% CI: 0.005-0.037,p < .001)demonstrated a reducing effect on tuses and child feeding practices by caregivers.Understanding the variations in undernutrition prevalence across different regions is vital for the development of targeted interventions and policies to address the specific challenges faced by each population.This highlights the need for context-specific approaches that consider the unique socioeconomic, cultural, and environmental factors contributing to undernutrition.Moreover, these findings emphasize the importance of ongoing monitoring and evaluation of nutrition interventions to ensure their effectiveness in combating undernutrition among settled pastoral children in northern Kenya.In the present study, children relying on public water pans or unprotected wells for drinking water exhibited a higher likelihood of stunting compared to those with access to safer water sources.These open water bodies in arid environments are susceptible to contamination from frequent sandstorms, potentially exposing children to diarrheal bacteria.Furthermore, limited access to toilets in the study areas was associated with increased stunting.This may contribute to open defecation, further contaminating the environment with harmful enteric pathogens.Children consuming water contaminated with these bacteria are at greater risk of contracting diarrheal diseases, known to impede growth and contribute to stunting.The notable diarrheal episodes in Bubisa ward can be explained by the fact that Bubisa is based in Chalbi desert and is prone to frequent sandstorms and open defecation is more common in the area.
and child's weight in tackling stunting among children in northern Kenya.Moreover, findings here highlight the poor waste disposal methods where the majority of households use open defecation and use of poorly ventilated temporary pit latrines, particularly in lowland wards where the prevalence of households without toilets is higher.Access to well-ventilated improved pit latrines in rural areas and use of flushable modern toilets in urban centers is crucial in promoting hygiene, preventing the spread of diseases, and improving the overall community health.
ward and wasting in the Bubisa ward.Family size directly impacts the allocation of food resources within households, with younger children typically receiving priority over those aged two and above.These findings are consistent with a prior investigation conducted in Ethiopia by Abera et al. (2019), which identified a notable correlation between larger family sizes and the prevalence of undernutrition among nonpastoral children under 5 years in Tigray, Ethiopia.Similarly, research conducted by Ahmad et al. (2019) in Pakistan demonstrated a significant link between family size and various indicators of undernutrition.Their findings indicated that family sizes ranging from 1 to 5 members had a mitigating effect on stunting and wasting.

Table 1
provides a summary of the population characteristics in the six selected administrative wards of Marsabit County.A total of 394 caregivers with children aged 6-59 months were interviewed, with the highest representation in the Sagante/Jaldesa ward (29.9%) and the lowest in the Logologo ward (10.9%).The majority of households were TA B L E 1 Mean ± SEM of population characteristics in different wards in Marsabit County.
Frequencies of population characteristics in different wards in Marsabit County.
ployed caregivers were less likely to be stunted (AOR = 0.603, 95% CI: 0.437-0.832,p=.002).In the study area, children who belonged to households with inadequate access to toilet facilities had a 3.8fold increased likelihood of being stunted (AOR = 3.797, 95% CI:1.863-7.737,p< .001).Additionally, appropriate disposal of child fecal waste was associated with a significantly lower likelihood of F I G U R E 3 Percentage of households using different treatment methods for drinking water by ward (N = 394: χ 2 ; p < .001).TA B L E 2 Values with the same letters are not significantly different at p < .05.Prevalence of stunting, wasting, and underweight among children by age group and ward.
† 1USD = KES 150.00.TA B L E 2 (Continued) F I G U R E 4 Mean nutritional status of children by ward (N = 394).Error bars represent the 95% confidence interval: χ 2 ; p < .001.TA B L E 3 Overall odds ratio (OR) of factors associated with undernutrition among children 6-59 months in Marsabit County.
Note: Values with the same letters are not significantly different at p < .05.TA B L E 3 (Continued) TA B L E 4

Table 2
). Settled households with children under the age of 5 faced significant limitations in accessing livestock products.Either the livestock was taken far in search for pasture and water or they would have died due to lack of feeds and water.The Rendille community, who live Prevalence of stunting, wasting, and underweight among children by sex and ward.Note: Values in parentheses are the percentages, and those outside are frequencies.
was 16 years (not reported in the table), indicating the occurrence of early marriages among pastoral girls, which could potentially lead to teenage motherhood and subsequently poor feeding practices, thereby contributing to a higher incidence of undernutrition among children.These findings are consistent with those of prior research by Mbijiwe et al. (2022) and Morakinyo et al. (2020), TA B L E 6